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Contents lists available at ScienceDirect

Auris Nasus Larynx

journal homepage: www.elsevier.com/locate/anl

Stapedotomy with incus vibroplasty – A novel surgical solution

of advanced otosclerosis and its place among existing therapeutic
modalities – Hungarian single institutional experiences
Andras Burian a,*, Imre Gerlinger a, Tamas Toth a, Zalan Piski a, Gabor Rath b,
Peter Bako a
a
University of Pécs, Department of Otorhinolaryngology, Pécs, 7621, Munkácsy M Str 2, Hungary
b
University of Pécs, Department of Paediatrics, 7623, Pécs, József Attila Str 7, Hungary

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To delineate the advantages and steps of stapedotomy with incus vibroplasty, to assess
Received 1 April 2018 the safety and efficacy of this method via the authors’ experiences, and to overview the literature
Accepted 18 April 2019 regarding other surgical options in advanced otosclerosis determining the place of stapedotomy with
Available online xxx
incus vibroplasty in the therapeutic range.
Methods: Four patients were enrolled in the study presenting severe mixed hearing loss of at least
Keywords:
one side on pure tone audiometry. Based on complementary audiological examinations including
Active middle ear implant
Advanced otosclerosis
stapedial reflex test and multifrequency tympanometry, all cases were suspected as advanced
Laser stapedotomy otosclerosis. Stapedotomy with incus vibroplasty – the combination of laser stapedotomy and
Mixed hearing loss simultaneous Vibrant Soundbridge implantation – was performed in each patient. Preoperative pure
tone average, speech recognition thresholds and word recognition scores were compared to one-year
postoperative free-field values with the implant switched on focusing on functional gain.
Results: Among 4 participants (3 females, 1 male) the mean age (SD) was 66 years (35). In three
cases Nitinol, in one case NitiBond piston was inserted. One-year postoperative free-field functional
gains were 30 dB, 34 dB, 42 dB and 51 dB, respectively. One-year postoperative free-field speech
recognition thresholds were 45 dB, 45 dB, 49 dB and 50 dB, respectively, while word recognition
scores were 70%, 70%, 70% and 75%, respectively.
Conclusion: Postoperative results in our serie regarding pure tone average and word
recognition score proved to be better than those found in the literature. Stapedotomy with incus
vibroplasty – through sufficient air-bone gap closure and simultaneous sensorineural component
management – seems to be a promising surgical solution in advanced otosclerosis, requiring further
investigation.
© 2019 Elsevier B.V. All rights reserved.

* Corresponding author at: University of Pécs, Department of Otorhinolar- 1. Introduction

yngology and Head and Neck Surgery, 7621, Pécs, Munkácsy M Str 2,
Hungary.
Otosclerosis, also known as otospongiosis, is the primary
E-mail addresses: andras.burian@gmail.com (A. Burian),
imre.gerlinger@gmail.com (I. Gerlinger), thomasso.dhd@gmail.com (T. Toth), disease of the otic capsule and stapes footplate characterized by
zpiski@gmail.com (Z. Piski), rath.gabor@pte.hu (G. Rath), their pathological bony remodeling consisting of continuous
drbakopeter@gmail.com (P. Bako). bone resorption and development of dense, sclerotic lesions.
https://doi.org/10.1016/j.anl.2019.04.004
0385-8146/© 2019 Elsevier B.V. All rights reserved.

Please cite this article in press as: Burian A, et al. Stapedotomy with incus vibroplasty – A novel surgical solution of advanced otosclerosis and
its place among existing therapeutic modalities – Hungarian single institutional experiences. Auris Nasus Larynx (2019), https://doi.org/
10.1016/j.anl.2019.04.004
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This condition predominantly affects the Caucasian population
with a prevalence of 0.3–0.4% [1], appearing in the third decade
of life with a 2:1 female to male ratio. Initial clinical
manifestation is conductive hearing loss (CHL) due to stapes
fixation. The presence of associated moderate or severe
sensorineural hearing loss (SNHL) can be observed mostly
in advanced phase of the disease. Beside conductive or mixed
hearing loss (MHL) and the absence of stapedial reflex, clinical
diagnosis of otosclerosis is based on the presence of sclerotic
foci within the otic capsule detected on high-resolution
CT scan.
Treatment of stapes fixation associated with severe MHL is
currently a question under debate. For a long time, the only
existing therapy of advanced otosclerosis (AO) was the
combination of stapedectomy/stapedotomy with the use of
conventional hearing aids (HA) [2–4]. However, conventional
HAs can cause problems for many patients due to ear wax
accumulation, fitting problems, occlusion effect, recurrent
external auditory canal infections and other disturbing factors
such as itching and cosmetic problems [5,6]. Furthermore,
management of CHL with stapedotomy alone does not always
result in adequate hearing improvement in AO due to the
co-existence of sensorineural component [7]. Cochlear implan-
tation (CI) has also started to play an important role in the
management of AO, however this procedure can have
disadvantages such as facial nerve stimulation (FNS) due to
inadequate insertion because of possible cochlear involvement
[8]. Along with the rapid development of passive middle ear
implants (e.g. pistons, prostheses) [9,10], there was a growing
demand for middle ear surgical solutions of SNHL. Introduc-
tion of active middle ear implants (AMEI) – e.g. Vibrant
Soundbridge (VSB) (MedEl, Innsbruck, Austria) – has opened
new ways for the management of CHLs, mild-to-severe pure
SNHLs or MHLs [11–14] starting to gain space in the
management of AO. Therefore, in cases of stapes fixation and
associated moderate or severe MHL, the role of conventional
HAs in the management of the sensorineural component is
being gradually replaced by AMEIs. Stapedotomy and
simultaneous VSB implantation – the so called stapedotomy
with incus vibroplasty (SWIV) procedure – can be a promising
solution for AO, improving both components of MHL.
To this date, SWIV is barely mentioned in the literature
[15–17]. Furthermore, to the best of our knowledge, this paper
possesseses the highest number of patients undergoing SWIV
with insertion of VSB within one study in AO. In addition to
detailing the steps, indications and advantages of this technique,
we present our experiences gained with this combined
procedure alongside the literature concerning other surgical
options related to AO.
2. Methods
This case serie study was conducted between March 9th,
2016 and May 5th, 2017 in a tertiary university center. Four
patients were enrolled in the study with the selection criteria of at
least one-sided moderate-to-severe MHL and associated stapes
fixation. Hearing in each case had been stable for two to four
years. Preoperative evaluation included routine microscopic ear
Please cite this article in press as: Burian A, et al. Stapedotomy with incus vibroplasty – A novel surgical solution of advanced otosclerosis and
its place among existing therapeutic modalities – Hungarian single institutional experiences. Auris Nasus Larynx (2019), https://doi.org/
10.1016/j.anl.2019.04.004
examination and subjective audiological examinations including
bilateral pure tone average (PTA), speech recognition threshold
(SRT) and word recognition score (WRS) measurements. PTA
was determined by averaging hearing levels at 500, 1000,
2000 and 3000 Hz. Audiograms, SRT and WRS values were also
recorded with HA under free-field conditions as shown in
Tables and on Fig. 1–4. The estimated FG with HA was calculated
in each case. More amplification caused acoustic feedback and
occlusion effect that our patients could not tolerate. As part of the
preoperative objective examinations, multifrequency tympano-
metry (MFT), stapedial reflex test (STR) and vestibular evoked
myogenic potential (VEMP) tests were performed. Preoperative
high-resolution CT scan was performed in each case to evaluate
surgical anatomy including middle ear cavity, facial nerve canal,
position of the jugular bulb and ossification status of the oval and
round window. Nevertheless CT scan was applied for exclusion
of inner ear pathology and other associating causes of CHL and
MHL including fusion of the ossicules, ossicular chain
discontinuity and chronic inflammatory middle ear disease,
respectively. All participants underwent SWIV procedure, the
combination of VSB implantation and laser stapedotomy using
Nitinol SMart1 (Olympus, Hamburg, Germany) or NitiBond1
(Kurz, Dusslingen, Germany) piston. Postoperative one-year
posstapedotomy PTA, free-field unaided/aided PTA, SRT and
WRS values were also recorded and compared to preoperative
values determining functional gain (FG) and speech reception
improvement (Tables and Fig. 1–4). Free-field measurements
were performed in quite. The non-operated contralateral side ears
were masked with white noise applied via headphone. Masking
levels are demonstrated in each case below.
3. Surgical technique
The steps of this combined approach (retroauricular-
transcanal) surgery are as follows: first, mastoidectomy and
posterior tympanotomy are carried out visualizing the
incudostapedial joint and confirming fixation of the stapes
footplate. Adequate width of the posterior tympanotomy is
checked by introducing the dummy of the VSB’s floating mass
transducer (FMT). The bony bed for the VSB is made behind
the mastoidectomy cavity by drilling. Using its attachment clip,
the FMT is most frequently placed on the long process of incus
through the opening of the posterior tympanotomy. Using a
short process coupler, the FMT can alternatively be attached to
the short process of the incus (Fig. 5), in which case no posterior
tympanotomy is required. Elevating the tympanomeatal flap,
the tympanic cavity is exposed for stapedotomy. Release of the
incudostapedial joint is followed by cutting the tendon and
crura of the stapes with KTP laser. Using the laser, a rosette is
created at the border of the middle and posterior thirds of the
stapes footplate initiating fenestration. Fenestration is complet-
ed with microdrill. Nitinol SMart1 or NitiBond1 pistons are
inserted in the stapedotomy opening and then fixed on the long
process of incus with KTP laser impulses using the pistons’
self-crimping, thermal shape memory features. Positioning
of the FMT prior to the insertion of the piston is essential, as
reverse order may lead to inner ear damage caused by the
manipulation with the FMT on the incus resulting in direct
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Fig. 1. Preoperative bilateral pure tone audiograms, hearing aided free-field audiograms, poststapedotomy pure tone average and free-field tresholds with VSB of case 1.

forces to the cochlea. A small piece of fascia is harvested and
placed around the piston to seal the leakage of the perilymph.
Both the piston and the FMT are fixed on the long process of
incus with glass ionomer cement preventing their malposition
(Fig. 6). The tympanomeatal flap is laid back and a loose
package is applied in the external auditory canal, while
retroauricular incision is sutured intracutaneously with absorb-
able suturing material finishing the surgery.
4. Results
Our serie included three females and one male with the ages
ranging from 35 to 70 years. The preoperative microscopic ear
examination revealed no abnormalities. On pure tone audiom-
etry, severe mixed hearing loss was recorded at all participants
with congruent SRT and low WRS values. Besides severe
MHL, no STR could be recorded. Nevertheless, MFT showed
high resonance frequencies suggesting AO. VEMPs could be
bilaterally registered in all cases up to 85 dB excluding the
existence of “third window syndrome”. Stapes fixation could be
confirmed intraoperatively in all cases. Half of the patients
received Nitinol SMart1 piston, while the others came in for
NitiBond1 piston insertion. No intra – or postoperative
complications were noted in the serie. FG regarding PTA
and improvement of SRT and WRS is demonstrated individu-
ally in each case below (Tables and Fig. 1–4).
4.1. Case 1
H. G., a 70-year-old female diagnosed with left side MHL
with 86 dB PTA and 45 dB ABG (Fig. 1). The patient did not
intend to wear HA because of cosmetical considerations.
Preoperative CT scan showed enlarged oval window without
obvious sign of retrofenestral involvement. Preoperative SRT
was 85 dB, WRS proved to be 0%. The FMT was attached to the
long process of incus and Nitinol SMart1 piston was used for
ossicular chain reconstruction. One-year postoperative PTA
was found to be 61 dB with 20 dB ABG. Postoperative free-
field PTA was 62 dB without, and 44 dB with implant, resulting
in 42 dB FG. One-year postoperative SRT was 63 dB without,
and 45 dB with implant, respectively. Free-field WRS was 10%
without, and 70% with implant after one year, respectively.
Masking level of the contralateral side ear was 90 dB.
4.2. Case 2
B. I., a 64-year-old male diagnosed with severe MHL on the
left side. Preoperative PTA was 75 dB with 25 dB ABG (Fig. 2).
In his case wearing HA failed due to recurrent external auditory

Please cite this article in press as: Burian A, et al. Stapedotomy with incus vibroplasty – A novel surgical solution of advanced otosclerosis and
its place among existing therapeutic modalities – Hungarian single institutional experiences. Auris Nasus Larynx (2019), https://doi.org/
10.1016/j.anl.2019.04.004
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Fig. 2. Preoperative bilateral pure tone audiograms, hearing aided free-field audiograms, poststapedotomy pure tone average and free-field tresholds with VSB of case 2.

canal infections. In this case the high-resolution CT scan also
revealed solely fenestral involvement by showing enlarged oval
window without cochlear manifestation. Preoperative SRT was
75 dB and initial WRS at 65 dB was 0%. The FMT was fixed on
the long process of incus and Nitinol SMart1 piston was
applied. Poststapedotomy PTA increased to 61 dB with a
remaining 16 dB ABG. Unaided free-field PTA became 63 dB,
while aided PTA value changed to 45 dB, achieving 30 dB FG.
Unaided SRT improved to 64 dB, aided value was 45 dB.
Unaided 10% WRS changed to 75% with implant switched on.
Masking of the contralateral side ear was performed with 50 dB
till 2000 Hz, while above it the masking level was 70 dB.
4.3. Case 3
B. A., a 35-year-old female with severe MHL on the left side.
Preoperative PTA was 99 dB with 50 dB ABG (Fig. 3),
associated SRT was 95 dB with 0% WRS. She could not tolerate
HAs owing to occlusion effect and disturbing ear wax
accumulation. The preoperative CT examination showed no
“double-ring” effect suggesting pure fenestral location of
sclerotic foci. The FMT was again clipped on the long process
of the incus and NitiBond1 piston was inserted. Poststape-
dotomy PTA improved to 74 dB with a remaining 30 dB ABG.
Free-field PTA was 76 dB without, and 48 dB with implant.
Due to SWIV, 51 dB FG could be reached. SRT decreased to
77 dB without, and 49 dB with implant. Regarding WRS, beside
0% unaided value 70% could be reached with implant. Masking
of the contralateral side was performed with 70 dB till 2000 Hz,
while above it 80 dB was applied.
4.4. Case 4
H. J., a 65-year-old female diagnosed with severe right side
MHL. Preoperative PTA was 83 dB with 35 dB ABG (Fig. 4).
SRT was 85 dB with 0% WRS. She refused HA fitting due to
reservations about cosmetical results. Preoperative CT scan
demonstrated thickened footplate and narrowed oval window
without “double-ring” effect showing fenestral form of
otosclerosis. In her case, no posterior tympanotomy was
performed: the FMT was attached directly to the short process
of the incus using a short process coupler (MedEl, Innsbruck,
Austria). NitiBond1 piston was applied after fenestration.
Poststapedotomy PTA improved to 60 dB with a remaining
14 dB ABG. Unaided free-field PTA was 61 dB, aided PTA was
49 dB. With SWIV, 34 dB FG could be reached. SRT decreased
to 62 dB without, and 50 dB with implant. Unaided 10% WRS
improved to 70% with implant switched on. Masking of the
non-operated ear was provided by 80 dB till 1000 Hz, the higher
frequencies were masked with 100 dB.

Please cite this article in press as: Burian A, et al. Stapedotomy with incus vibroplasty – A novel surgical solution of advanced otosclerosis and
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10.1016/j.anl.2019.04.004
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Fig. 3. Preoperative bilateral pure tone audiograms, hearing aided free-field audiograms, poststapedotomy pure tone averages and free-field tresholds with VSB of case 3.

5. Discussion negligible. FNS was widely reported by several authors as the

Since Shea’s first stapedectomy with teflon prosthesis
insertion in 1956 [18], stapes surgery has undergone several
changes due to technical developments permitting less invasive
manipulation on stapes footplate. One of the most remarkable
advances following Plester’s partial stapedectomy [19]
pioneering minimal invasiveness was the introduction of
stapedotomy first described by Shea and Fisch [20,21]. Over
the past decades, introduction of lasers and microdrills in
middle ear surgery has made stapedotomy a safer and more
reliable procedure, offering a minimally traumatizing solution
for closure of ABG due to stapes fixation. Several studies have
demonstrated that laser-assisted stapedotomy comes with
reduced risk of footplate fracture and subsequent inner ear
injury compared to conventional stapedectomy [22–24].
Nevertheless, in AO stapedotomy alone does not always
provide satisfactory results due to the associated sensorineural
component [7]. This component is considered as a relevant
factor in the successful treatment of AO and has traditionally
been treated with conventional HAs for a long time [2–4]. CI is
also a possible option to take into consideration especially in far
advanced otosclerosis (FAO) [25,26]. However, postoperative
complications generally related to CI in otosclerosis are not
most frequent unintentional effect of this procedure, especially
in far advanced cases [8,27–29]. Frijns et al. using a
computational model explained this undesirable effect with
the increased conductivity of the otospongiotic bone resulting in
easier excitation of the facial nerve [27]. Rotteveel et al. pointed
to the relatively high, approximately 38% occurrence rate of
FNS after CI in case of otosclerosis compared to non-
otosclerotic patients [28]. Intracochlear cavity formation caused
by increased demineralization can also promote reduced
distance between the electrode and facial nerve, published by
Ramsden et al. [29]. According to the same study, intracochlear
obliteration caused by extensive otospongiotic foci has also a
higher risk of partial insertion and subsequent misplacement of
the electrode resulting in FNS. In a recently published meta-
analysis, Abdurehim et al. suggested stapedotomy as the first
step before CI in AO especially in case of acceptable speech
recognition with an adequately fitted HA [30]. Lower costs of
stapedotomy, and its lower level of invasiveness compared to
CI are also considerable advantages, while offering a more
natural sound experience [2]. Furthermore, stapedotomy
performed prior to CI still allows maintaining CI as a salvage
solution [30]. Whether stapedotomy with HA fitting or CI is
primarily preferable in AO remains a controversial question.

Please cite this article in press as: Burian A, et al. Stapedotomy with incus vibroplasty – A novel surgical solution of advanced otosclerosis and
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10.1016/j.anl.2019.04.004
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Fig. 4. Preoperative bilateral pure tone audiograms, hearing aided free-field audiograms, poststapedotomy pure tone averages and free-field tresholds with VSB of case 4.

Advantages of laser-assisted stapedotomy [22–24] and dis-
advantages of conventional HAs [5,6] have created the need to
develop an alternative procedure that simultaneously
improves the sensorineural component without the use of HAs.
Replacement of HAs could become a reality owing to AMEIs
[31,32] directing the environmental sound as mechanical
vibrations to the inner ear via one of the ossicles. The technical
immaturity of initially used partially implantable AMEIs
emerged more reliable technical background. The first
application of VSB in 1996 by Fisch is regarded as an
outstanding milestone in the history of AMEIs. Since its market
introduction, this partially implantable hearing device is the
most widely used AMEI. In the early 2000s, VSB has been
implanted only in adults with mild-to-severe SNHL [11,14].
Since then, its indication area has been extended not only to
children and adolescents [33,34], but to patients with CHLs or
MHLs as well [12,13]. The wide clinical applicability of VSB is
due to the shape of the FMT’s single-point attachment clip and

Fig. 6. FMT (asterisk) and the loop of piston (arrow) positioned on the long
Fig. 5. FMT (asterisk) coupled to the short process of incus through antrotomy process of incus reinforced with glass ionomer cement to prevent their
opening. malpositions.

Please cite this article in press as: Burian A, et al. Stapedotomy with incus vibroplasty – A novel surgical solution of advanced otosclerosis and
its place among existing therapeutic modalities – Hungarian single institutional experiences. Auris Nasus Larynx (2019), https://doi.org/
10.1016/j.anl.2019.04.004
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feasible couplers, easing its fixation to any of the middle ear
structures chosen as potential vibrational structure. Thus, the
frequently used term vibroplasty as a synonym refers to the
implant’s working mechanism. Initially, only incus vibroplasty
existed as VSB for the treatment of moderate-to-severe SNHL
[11,14] by augmenting the natural movement of the ossicular
chain along with sound amplification. Mainly patients who
refused, or could not tolerate conventional HAs could benefit
from VSB. During incus vibroplasty, the FMT is most
frequently coupled to the long process of incus through a
posterior tympanotomy opening. Placing the FMT on the short
process of the incus is an alternative way of coupling, making
posterior tympanotomy unnecessary and avoiding its possible
complications, including facial nerve or chorda tympani injury.
Short process coupling requiring only an extended antrotomy is
considered a less invasive technique, providing the same
audiological results as the “pioneer” long process coupling, as
demonstrated on a human cadaveric study by Shraven et al.
[35]. Furthermore, conductive and MHLs, including failed
tympanoplasties, chronically disabled middle ears, and oto-
sclerosis could also be enrolled in the indication area due to the
alternative coupling techniques. Huttenbrink et al. reported
favorable results with oval window (OW) vibroplasty, by
coupling the FMT to the stapes footplate using total ossicular
replacement prosthesis [36]. These audiological results were
similar to when the FMT was attached to the stapes
superstructure with a self-made clip [37,38]. Colletti and
Baumgartner advocated preferring round window (RW)
application of VSB as a solution for unsuccessful ossiculo-
plasties through bypassing chronically disabled middle ear
function and reverse driving of the cochlea by positioning the
FMT in the RW niche (RWN) [12,13]. Therefore, RW
vibroplasty is considered as an innovative application of
VSB also in the surgical management of otosclerosis [39]
bypassing the stiffness of the ossicular chain. Although Chen
et al. found no difference between forward and reverse
stimulation of the basilar membrane [40], postoperative results
can be variable. These variable results are due not only to the
specially designed couplers but also due to the materials (e.g.
fascia, perichondrium, Tutoplast, processed allograft pericardi-
um) used for the reinforcement of the FMT in the RWN. As a
possible cause of unsatisfactory hearing results, migration of
the FMT from the RWN was reported by Rajan et al. [41]. Soft
tissue reinforcement, though providing physical contact
between the FMT and the RW membrane, can simultaneously
hinder the real coupling effect [12]. However, the risk of inner
ear damage has more clinical relevance. An unintentional inner
ear damage during RW vibroplasty can occur not only during
widening RWN, but the undesirable noise effect of drilling can
be similarly harmful for the cochlea as it was observed in CI
[42]. Delayed development of RW fistule by long-standing
pressure of FMT has also been reported [43]. As part of the
gradually widening indication area of vibroplasty, congenital
outer and middle ear malformations also seem to be promising
candidates for VSB application. Unilateral osseuos atresias can
be circumvented by placing FMT on the RW or on the stapes
suprastructure but coupling FMT alternatively on malleus-incus
complex frequently observed in such cases also comes into
Please cite this article in press as: Burian A, et al. Stapedotomy with incus vibroplasty – A novel surgical solution of advanced otosclerosis and
its place among existing therapeutic modalities – Hungarian single institutional experiences. Auris Nasus Larynx (2019), https://doi.org/
10.1016/j.anl.2019.04.004
7
question as it was demonstrated by Frenzel et al. [44]. VSB [45]In
bilateral cases Beside its efficacy and safety, better audiological
results and acceptance of VSB compared to conventional bone
conducting hearing devices also allows the application of VSB in
children and adolescents suffering unilateral osseous atresia as it
was reported by Leinung et al. [46].
Despite pros and cons, many authors conclude that
vibroplasty provides better speech perception in noisy
environments, particularly at conversational levels and at
higher frequencies compared to ossiculoplasties combined with
conventional HAs [47,48].
Continuing both technical and surgical innovation, combi-
nation of laser-assisted stapedotomy and insertion of AMEIs –
the so called SWIV procedure – seems to open new ways in the
successful treatment of AO. To the best of our knowledge, only
two papers – published by Dumon and Venail – are available in
the literature dealing with this combined procedure improving
the conductive and sensorineural components simultaneously in
AO [15,16], the latter of which preferring MET instead of VSB.
As a promising therapeutic option, SWIV was mentioned also
in connection with osteogenesis imperfecta by Kontorinis et al.
[17].
To this day, no case report is available in the literature
dealing with more than one case of SWIV obligately applying
VSB regarding AMEI choice. Taking the relatively poor
literature and novelty of this surgical technique, we aimed to
focus on its detailed description and its place within the
therapeutic range of AO summarizing the existing surgical
possibilities applied in otosclerosis. Furthermore, this paper
demonstrates our institutional experiences gained with SWIV, a
novel and promising surgical solution of AO.
Considering the relatively low number of AO patients
candidated for this type of surgery with their moderate-to-
severe MHLs, establishing the indication criteria is as initial as
the technique itself. In our opinion, the “key” point is the
indication of VSB that is suggested according to the selection
criteria of VSB proposed for pure SNHLs. Thus, sufficient
closure of ABG is followed by further hearing improvement by
VSB aiming sensorineural component. Corresponding to our
patients, real candidates of SWIV are those individuals with AO
who do not will to wait until the optimal time for CI and neither
will to wear conventional HAs for any reason.
As demonstrated above, notable hearing improvement could
be reached in all cases (Tables 1 and 2.). Poststapedotomy
results may seem to be insufficient, but considering these cases
as AOs, postoperative PTA and ABG values are acceptable.
Nevertheless, comparing preoperative audiometry values to
one-year postoperative aided free-field results, improvement in
our serie is remarkable and better than those found in the
literature [15,16] regarding PTA and WRS. Nevertheless all of
our patients are satisfied also subjectively with the achieved
hearing improvement. Furthermore, no postoperative compli-
cations were observed during follow-up and audiological
results remained stable even after one year. Our patients were
all satisfied and reported good experiences and appropriate
binaural hearing regarding their daily routine. In our opinion,
proper order of FMT positioning and piston insertion is
essential for maximum protection of inner ear function.
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Table 1
Tables Pre - and one-year postoperative hearing results including pure tone average measurements (Table 1) and speech reception values (Table 2).

Pure tone average (PTA) (dB)

Case Sex Age Age of Progressive Piston Bilat. mean Bilat. ABG Free-field Functional Poststapedotomy ABG Free-field HL Functional
(yrs) onset of hearing loss preop. HL preop. HL w/HA gain w/HA HL posto. postop gain w/VSB
hearing preop
loss (yrs)
Left Right Left Right w/o VSB w/VSB
side side side side
1 Female 70 40 No (stable for 3 yrs) Nitinol 86 66 45 21 78 8 61 20 62 44 42
2 Male 64 48 No (stable for 2 yrs) Nitinol 75 29 25 0 68 7 61 16 63 45 30
3 Female 35 25 No (stable for 3 yrs) NitiBond 99 39 50 10 86 13 74 30 76 48 51
4 Female 65 43 No (stable for 4 yrs) NitiBond 66 83 11 35 76 7 60 14 61 49 34

A. Burian et al. / Auris Nasus Larynx xxx (2019) xxx–xxx

ABG: air-bone gap; HA: hearing aid; HL: hearing level; w/HA: with hearing aid;
w/VSB: with Vibrant Soundbridge; w/o VSB: without Vibrant Soundbridge.
The underlines represent the side of ear planned for surgery.

Table 2
Tables Pre - and one-year postoperative hearing results including pure tone average measurements (Table 1) and speech reception values (Table 2).

Speech reception
Case Sex Age Piston Speech recognition treshold (dB) Word recognition score (%)
(yrs)
Left side Right side Free-field Improvement Free-field postop. Improvement Left side Right side Free-field Improvement Free-field postop. Improvement
preop preop w/HA preop w/HA w/VSB preop preop w/HA preop w/HA w/VSB
w/o VSB w/VSB w/o VSB w/VSB
1 Female 70 Nitinol 85 70 78 7 63 45 40 0 0 0 0 10 70 70
2 Male 64 Nitinol 75 25 68 7 64 45 30 0 100 0 0 10 75 75
3 Female 35 NitiBond 95 35 86 9 77 49 50 0 95 0 0 0 70 70
4 Female 65 NitiBond 45 85 76 9 62 50 35 80 0 0 0 10 70 70
w/HA: with hearing aid; w/VSB: with Vibrant Soundbridge; w/o: without Vibrant Soundbridge.
The underlines represent the side of ear planned for surgery.
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Positioning the FMT prior to piston insertion must be
emphasized, otherwise, the piston may directly transmit the
mechanical energy caused by the manipulation of FMT to the
inner ear, inducing unpredictable cochlear damage. The one-
step nature of the procedure means less stress for patients.
Furthermore, we believe that this retroauricular-transmeatal
approach provides excellent visualization of the surgical field,
enabling gentle manipulations with both the piston and the
FMT. In one case of the series, the FMT was attached to the
short process of incus. Short process coupling does not require
posterior tympanotomy, theoretically further reducing inva-
siveness, surgical time and risk of unintended facial nerve or
chorda tympani injury related to performing posterior
tympanotomy, although remarkable difference in surgical time
between the two coupling techniques was not noticable in our
practice. In our serie selection of piston – Nitinol or NitiBond –
was based on availability of each type. As a complementary
investigation, VEMP test is strongly suggested to exclude the
presence of superior semicircular canal dehiscence syndrome
related “third window syndrome” resulting in false ABG on
pure tone audiogram. Preoperative high-resolution CT scan is
strongly suggested to evaluate middle and inner ear anatomy,
running of the facial nerve, position of jugular bulb and
ossification the oval and round. Furthermore, CT-based
radiological exclusion of other possible associating causes of
conductive, sensorineural and mixed hearing losses including
congenital ossicular fusion, ossicular discontinuity and chronic
purulent otitis media is also neccessary. Beside VEMP, CT scan
also can be helpful in exclusion of superior semicircular canal
dehiscence syndrome. Nevertheless we assessed the presence of
retrofenestral otosclerotic foci on CT images for further
comparison and for estimation of the success of an electrode
insertion in case of a possible necessary CI in the future.
According to the classification system proposed by Rotteveel
et al. [28], all of our patients had Type I otosclerosis
representing the solely fenestral form of the disease without
any radiologic sign of cochlear sclerosis.
5.1. Limitations
The majority of patients with AO in our practice – despite of
meeting the indication criteria of SWIV – were not willing to
undergo VSB implantation because of various reasons, which
explains the low case number.
The enrollment of more participants and their longer follow-
up is required to draw further conclusions regarding
permanency of hearing improvement.
6. Conclusion
Efforts on developing a one-step surgical procedure
simultaneously improving the conductive and sensorineural
components of AO came to the front in the past few years
replacing conventional HAs and eliminating their possible
disadvantages. During SWIV, effects of stapedotomy and VSB
implantation are added. From our experiences – noting that
more cases and long-term studies are necessary – SWIV seems
to be a reliable, safe and promising method in experienced
Please cite this article in press as: Burian A, et al. Stapedotomy with incus vibroplasty – A novel surgical solution of advanced otosclerosis and
its place among existing therapeutic modalities – Hungarian single institutional experiences. Auris Nasus Larynx (2019), https://doi.org/
10.1016/j.anl.2019.04.004
9
hands with proper indication representing a novel solution for
AO beside foregoing surgical solutions.
Declaration of authorship
IG conceived the study and critically reviewed the
manuscript. AB analyzed the data, prepared and drafted the
manuscript. PB and GR critically reviewed the manuscript. PB
and ZP substantially contributed to the comprehensive review
of the literature. TT edited the figures and tables and performed
the audiological measurements. All authors gave the final
approval of the manuscript and agreed to be accountable for all
aspects of the work in ensuring that questions related to the
accuracy or integrity of any part of the work are appropriately
investigated and resolved.
Disclosure statement
All authors have completed the Unified Competing Interest
form at www.icmje.org and declare: no support from any
organization for the submitted work; no financial relationships
with any organizations that might have an interest in the
submitted work in the previous 3 years; no other relationships or
activities that could appear to have influenced the submitted
work.
Acknowledgment
The authors would like to acknowledge all patients who
participated in the present study.
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